Mark Bilsky, MD, is the William E. Snee Endowed Chair and vice chairman of clinical affairs for neurosurgery at Memorial Sloan Kettering Cancer Center in New York City.
He is also the chief of Memorial Sloan Kettering's multidisciplinary spine tumor service. Here, Dr. Bilsky outlines six thoughts on emerging technology for treating spinal disorders and diseases.
Question: What emerging technology are you most interested in today and why?
Dr. Mark Bilsky: As I am principally focused on spine tumors, the emerging technology reflects our interest in integrated care. From a surgical standpoint, a number of technologies are interesting:
1) The most interesting implant technology is PEEK-carbon fiber screw-rod constructs that may facilitate proton beam therapy without changing the instrumentation strategy.
2) The recently FDA-approved fenestrated screws provide an opportunity to shorten spine-tumor reconstructions. The major concerns that led to long pedicle screw constructs (minimum two levels above and below the index level) were the expectation of osteoporosis and adjacent segment tumor progression. Both of these issues are obviated with PMMA-screw augmentation, so that we typically perform instrumented single-level procedures above and below the level operated on, even for separation surgery.
3) Without question, another great advance has been image-guidance for screw placement, osteotomy planning and tumor resection. Robotic integration may improve this technology, but currently it is hard to see how it will improve simple image-guidance.
4) Minimally invasive surgery, particularly percutaneous pedicle screws, have been a major advance in treating pathologic vertebral body fractures with posterior-element involvement. These are patients who require stabilization without an open decompression and do not respond well to standalone kyphoplasty or vertebroplasty. Tubular retractors are gaining traction for decompression, but still have significant disadvantages for tumor resection.
5) Endoscopic transforaminal decompression for degenerative issues in the cancer population is a really interesting approach as many of these patients have had prior RT or surgery in the operative corridor. My partner, Ori Barzilai, MD, learned this approach from Christoph Hofstetter, MD, PhD, and has very effectively integrated this into our treatment armamentarium for degenerative disease and looking at the possibility of tumor resection.
6) Without question, the da Vinci Robot has been very effectively integrated into our treatment paradigms for benign paraspinal neurogenic tumors, such as schwannomas and ganglioneuromas. With thoracic surgery, we have begun to explore the use of this technology for resection of Pancoast Tumors including rib osteotomies. The da Vinci robot has the potential to markedly decrease the approach morbidity for both benign and malignant tumors.
While the surgical technology is really interesting, continued advances in stereotactic radiosurgery, such as high-dose hypofractionated conformal photon radiation therapy, will have a great impact on both metastases and primary malignant and benign tumors. Integrating effective radiation strategies will continue to decrease treatment morbidity and improve outcomes. Excellent control rates have been demonstrated for all tumor histologies, including chordomas, but the great advance may be combining radiation with biologics, for example VEGF-inhibitors and checkpoint inhibitors, both for local and systemic control.
A plethora of proton beam facilities have been opened over the last five years. This technology will probably have limited utility for metastatic disease unless hypofractionated strategies can be developed. Proton beam has been shown to be effective for primary spine tumors, such as chordoma and chondrosarcoma.
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